Medicare/Medicaid CMS Exam 52 Questions with Verified Answers,100% CORRECT

Medicare/Medicaid CMS Exam 52 Questions with Verified Answers What does CMS stand for? - CORRECT ANSWER Centers of Medicare and Medicaid services What are the requirements to qualify for Medicare? - CORRECT ANSWER 1. over 65 2. entitled to Railroad Disability Benefits 3. entitled to disability benefits (SSI) for 24 months 4. entitled to SSI due to Low Gehrig's Disease 5. with End Stage Renal Disease (ESRD) Medicare A - CORRECT ANSWER Hospital insurance No premium if paid Medicare taxes! Medicare B - CORRECT ANSWER Medical insurance Can choose to enroll if pay premiums Medicare C - CORRECT ANSWER Medicare Plan-private insurers Medicare Advantage Medicare D - CORRECT ANSWER Prescription drugs What places can a Med A pt go to? - CORRECT ANSWER 1. Inpatient hospitalization 2. SNF 3. Home health 4. Hospice 5. Acute rehab *HH can also be Med B! What places can a Med B pt go? - CORRECT ANSWER 1. Outpatient 2. Physician services 3. Durable medical equipment 4. Mental health services 5. Ambulance What is covered under Med C? - CORRECT ANSWER 1. Health maintenance org (HMO) 2. Preferred provider org (PPO) 3. Private fee-for-service (PFFS) 4. Point of service options (POS) 5. Medicare medical savings accounts (MSA) *similar to private insurances-but have different regulations! What is covered under Med D? - CORRECT ANSWER Voluntary enrollment with A or B coverage Medicare contracts with private companies Medigap benefits - CORRECT ANSWER Supplemental health insurance policy Fills "gaps" within original Medicare plan -basically covers some or most out of pocket Through private insurance companies *must enroll in BOTH part A and B within 6 months of eligibility for Medicare Who manages Medicaid? - CORRECT ANSWER At the Federal level=CMS At the state level=Department of Health and Human Services AKA it changes state->state!!! What are the requirements to qualify for Medicaid? - CORRECT ANSWER 1. Pregnant women and children under 6 who's income is at or below 133% federal poverty level (FPL) 2. Children 6-19 w/ family income up to 100% FPL 3. Certain children in foster care, adoption assistance programs, or disabilities 4. Non-elderly low income parents/caretaker relatives 5. Adults with disability (under 65) 6. Medicare recipients with low income *can ONLY be OVER 65 if have low income also! Medicaid expansion - CORRECT ANSWER 2014-state choice Coverage to non-elderly, non-disabled adults! Covers the "gap" for those who didn't qualify, but make too little to get private insurance *benefits state by lowering hospital/state costs of unpaid ER/health bills Medicare A reimbursement: Acute care - CORRECT ANSWER Inpatient Prospective Payment System (IPPS) DRG=covers all services given in hospital Medicare A reimbursement: Inpatient rehab - CORRECT ANSWER IRF PPS (IRF PAI)=inpt rehab facility prospective payment system/pt assessment instrument PT must report amount and mode of tx (concurrent, co-tx, group, individual) Inpatient rehab mode of tx: concurrent - CORRECT ANSWER 1:2 PT/PTA:pt's pt's performing DIFFERENT activities Inpatient rehab mode of tx: co-tx - CORRECT ANSWER +2:1 More than 1 therapist from different disciplines treating 1 pt at a time Inpatient rehab mode of tx: group - CORRECT ANSWER 1:2-6 pt's performing SAME activities Inpatient rehab mode of tx: individual - CORRECT ANSWER 1:1 Medicare A reimbursement: SNF - CORRECT ANSWER Case mix PPS (RUG!!!!!!!) "sniff the rug" 30 day rule=if need tx more than 30 days, must request before end of 30 days or will go back to hospital for min 3 days 100 calendar days benefit Medicare A reimbursement: home health - CORRECT ANSWER Home bound status must be met *can also be Med B! What are criteria for home bound status for HH? - CORRECT ANSWER 2 met: 1. need aid of supportive devices-use of special transportation, or assistance of another person in order to leave home OR leaving home is medically contraindicated 2. (MUST meet BOTH of these) normal inability to leave home AND leaving home requires a considerable and taxing effort Medicare B reimbursement: outpatient - CORRECT ANSWER FFS (fee for service) ACO (accountable care org) Medicare B: therapy cap - CORRECT ANSWER Cap for PT and SLP combine (OT separate) $1,940 paid per calendar year $3,700 exception-need KX modifier and medical necessity to extend therapy! *does NOT apply to Med C (Med advantage) What is an Advanced Beneficiary Notice of Non-coverage? (ABN) - CORRECT ANSWER Given to pt (beneficiary) to inform if service will not be covered by Medicare and pt will be responsible for paying-must explain why! Formal documentation of notification to pt! pt may request not to receive the service *GA modifier must be used on claim!!! CPT code modifiers - CORRECT ANSWER 2 digit codes that tells payer to pay for something they usually wouldn't OR used to give extra info 59, KX, or GA Medicare quality reporting programs - CORRECT ANSWER To ensure services they pay for are high quality Triple aim: 1. better care 2. improve health 3. lower costs What is IMPACT? - CORRECT ANSWER Improving Post-Acute Care Transformation Act of 2014 Expands reporting requirements for post-acute providers Uniform assessment instruments Physician quality reporting system-outpatient - CORRECT ANSWER System to report quality indicators Gives incentive to providers who report 6 measures on 50% or more Medicare pt's (won't get 2% reduction in pay) Functional limitation reporting - CORRECT ANSWER G-codes!!!!!!!!!! *MUST be submitted with severity modifiers! Determine largest functional limitation for pt and use G-code and severity modifier Categories: 1. mobility: walking and moving around (PT use most) 2. Changing and maintaining body position 3. Carrying, moving and handling objects 4. Self care 5. Other When do you use functional limitation reporting? - CORRECT ANSWER 1. onset of therapy episode 2. min. of every 10th visit 3. eval OR re-eval 4. limitation has ended and further PT is needed for different limitation 5. discharge How do you choose functional limitation? - CORRECT ANSWER Use valid/reliable assessment tools/objective measures If more than 1 primary limitation... -most clinically relevant to successful outcome OR -quickest/greatest functional progress OR -greatest priority for pt When do you report a goal functional limitation G-code? - CORRECT ANSWER EVERY TIME!!!! Medical review program is made up of...? and does...? - CORRECT ANSWER 1. MACs 2. Certs 3. RACs 4. ZPICs There to reduce Medicare improper payments ZPICs job? - CORRECT ANSWER Police men Look for fraud and investigate (not random) complex audits Work directly with FBI What is different about MACs? - CORRECT ANSWER They are geographical! Transmittals - CORRECT ANSWER National coverage decisions (NCDs)=CSM Local coverage decisions (LCDs) =MACs Levels of supervision: general - CORRECT ANSWER PT is NOT required to be on-site for direction and supervision, but MUST be READILY AVAILABLE Levels of supervision: direct - CORRECT ANSWER PT is PHYSICALLY PRESENT and IMMEDIATELY AVAILABLE for supervision. PT will have DIRECT CONTACT with pt during each visit. "Line of site" Levels of supervision: direct personal - CORRECT ANSWER PT is PHYSICALLY PRESENT and IMMEDIATELY AVAILABLE for supervision. Direction and supervision is CONTINUOUS throughout time of tasks performed. "attached at the hip" Medicare A intern requirements - CORRECT ANSWER Student considered an extension of PT Direct supervision-"line of site" Student can write documentation, PT co-signs Medicare A modes of therapy options - CORRECT ANSWER 1. Individual 2. Concurrent 3. Group Medicare B intern requirements - CORRECT ANSWER Direct personal-"attached at the hip" In order to be billed, PT must... -be present in room -direct services -make skilled judgement -is responsible for assessment and tx *can ONLY do 1:1 individual tx mode! *Billing MUST be done by PT What are 3 requirements for Medicare documentation? - CORRECT ANSWER 1. physician signature for certification 2. progress report every 10th visit 3. re-certification required every 90 days Medicare coverage guidelines - CORRECT ANSWER 1. Pt is "under care of a physician" 2. Services require skilled PT 3. Expectation that condition will improve significantly in reasonable time 4. Amount, frequency, and duration of service reasonable 5. Documentation reflects medical necessity Payable PT services must... - CORRECT ANSWER 1. show medical record and info on claim consistent and accurate 2. services that are covered by medicare 3. documentation must be legible, relevant, and sufficient to justify billing, and must comply with regulations! When can a Med pt get a re-evaluation? - CORRECT ANSWER 1. significant improvements 2. decline 3. change in pt's condition or functional status not anticipated in plan of care Initial certification - CORRECT ANSWER If Med pt does direct access, PT must get physician signature within 30 days! MUST document attempt to get signature Can get a verbal certification-must sign within 14 days What is a treatment encounter note? - CORRECT ANSWER Documentation required for EVERY tx day, EVERY therapy service done! Must include: -date -total tx time -each intervention/billed untimed and timed codes -detail of tx -signature -modification of tx What is a progress note? - CORRECT ANSWER Signature by physician NOT needed! Must be completed: -every 10 treatment days OR -at least once in 30 calendar days (whichever is less) What are some red flags for PT's? - CORRECT ANSWER 1. frequent use of KX modifier 2. in private practice-billing under 1 PT number instead of each separate PT enrolling 3. excessive # of codes billed per session